The Fundamentals of Preventing Retained Items

A tech-focused URSI-prevention blueprint bolsters the all-important manual count, it doesn’t replace it.

There are a lot of dedicated people working in hospital and surgery center operating rooms and one thing that’s certain among team members is there is never a question about the mission: To keep our patient safe.

Outside the hospitals, there also are industry experts out there every day exploring opportunities, developing strategies and creating products that will reduce the likelihood for errors in the OR.

Still, Unintended Retained Surgical Items (URSIs) remain at the top of virtually every top-10 list for healthcare associated risks. Simply put, we desperately want to make sure URSIs never happen. And yet, they still do.

Why URSIs

The top reason for URSIs essentially stems from “factors of human error” and the many components that increase those mistakes.

I usually find that the issue is related to a misperception of risk — you do something that’s dangerous enough times, you can forget that it’s inherently risky.

Another reason why URSIs happen is that system errors lead to problematic processes.

Take inaccurate preference cards. Think about it like this: If you are running a kitchen and your recipe card is wrong, you will always have some missing ingredients. In the OR, inaccurate prerence cards create chaos in the room, which increases stress and makes it much more likely for things to get missed.

Communication breakdown, it’s always the same

In almost every case I review or department I survey, there is some component of communication that has broken down. The best way to manage a good OR and reduce the risks therein is to remove barriers to safe care. The downstream problems, for the most part, tend to take care of themselves. There is also the interpersonal dynamics of the OR to contend with. In every work environment, you have people you prefer to work with more than others. Sometimes that dynamic can create problems, particularly where you’re relying on team communication to keep someone safe.

Staff morale is crucial in a healthcare environment. I believe that the right systems, when they work well, create high morale. When staff face little conflict, they (maybe sometimes literally) bang their heads against the wall less often have more positive interactions that ultimately keeps the patient safer.

For example, the preference card, the availability of supplies, the accuracy of the scheduling, the preparation of the staff and that each individual’s skill set is appropriately matched — all of this ensures the team is doing exactly what it should be doing during every procedure.

To create this type of efficiency, I rely on analytics, and I really try to advocate for facilities to commit their resources to analytics around perioperative care. Hire someone full-time and allow them to feed the department quality data. Create an infrastructure around reporting, collecting and integrating that data into systems. After all, if 80 percent of gross revenue for hospitals comes from surgical procedures, isn’t it worthwhile to invest in technology that will ultimately improve your OR ROI?

I believe that the right systems, when they work well, create higher morale.

The major electronic health record vendors are the largest providers of health information technology and are used primarily by large U.S. hospitals and health systems to access, organize, store and share electronic medical records.

Data is wonderful, but there are potential issues. For instance, one venfor created an environment where the preference cards drive everything downstream. Because of that, the OR systems can be very hard to manage, as relying on preference cards so heavily comes with the imperative that the cards must be meticulously maintained and accurate. The OR is more like a factory than other hospital units. Defects and systems are just as important as the quality of provider care.

Count on the count

Aside from focusing on the systems and human factors of error, there’s a tried-and-true method of surgical counting that has been used for years to reduce one of the most impactful defects an OR can produce: URSIs. The count is performed audibly by two OR team members, most commonly the scrub and circulator roles. Every procedure, unless not indicated, should include three counts: the initial count; the closing count when the surgeon is closing the cavity; and the final count prior to the final suture.

There are many reasons URSIs occur, but many of them happen because of confirmation bias — somebody else tells you that they think everything is OK, and nobody wants to delay the case. The assumption that the item is probably lost and there’s a reasonable explanation for that can be the fatal error in protecting a patient. There are many explanations that include the item probably wound up in the wastebasket or the sharps container.

The wound exam

The Association of periOperative Registered Nurses (AORN) and industry publications talk a lot about the standard of care for surgical counts. A large part of it is centered around counts and how nurses can collaborate with surgeons. We have many effective, standardized processes that have reduced URSIs and protected patients over the years. One thing that I believe perhaps doesn’t get as much attention as it should is wound exploration.

The wound exploration is such an important part of the surgical count process and it is exclusively within the surgeon’s purview. Nobody else is inside the wound. I think sometimes the surgeon is so used to the staff being dedicated, rigid and committed to quality that they forget that they’re the very last opportunity to find the error. They are the backstop.

As many of us know, it is not difficult to leave a sponge inside someone, especially if the surgeon is working behind a cavity and the sponge is tucked deep inside.

Of course, it’s everybody’s responsibility to keep the patient safe, but when the last check is the surgeon that sweeps the room, and there’ some indication that didn’t occur, it is a failure that has missed so many protective measures that it is hard to stomach. There must be a way to improve on the work we have done without the solution of simply “trying harder!”

Technologies to prevent errors

OK COMPUTER Technology isn’t intended to be the primary source of count verification — it’s meant as a backstop for processes that can be easily disrupted without deliberate management and tracking.

Adjunct technology essentially breaks down into three categories: barcode scanning; a radio frequency identification (RFID) wands and similar technology; and radiological studies. Barcode scanning platforms allow the OR team to determine whether a sponge is missing, by standardizing the count and reinforcing the feedback, not unlike a grocery checkout line. RFID technology can truly act like a magic wand: detecting that which has eluded our best efforts. Using X-rays to find RSIs and URFIs isn’t used as much these days because of our shared work to reduce avoidable patient radiation doses. It goes without saying that the risks of radiological testing makes the other two methods that have no radiation dose more attractive.

These two practices are similar to radiology in that they serve as an underlying safety net. But they’re not intended to ever be used as the primary source of verification. They are the backstop for processes that can be easily disrupted without deliberate management and tracking.

Staff training

One of the training methods I utilized when I was a director at a trauma I research system was to pull information from electronic records that revealed where each of our OR staff was spending their clinical time.

The data told us the types of procedures, services, minutes, and days that staff members had spent their clinical repetitions over a 90-day period. We were trying to determine if the right people were in the right procedures at the right times.

Once the report was developed by our team, that information was available with the push of a button, and allowed us to realign our priorities.

This report not only gave the surgeons more information on how to improve the availability of their teams, it gave them a deeper bench. This report, coupled with an overlay of surgeon schedules, block schedules, staffing schedules, and vacations, gave us a predictive analytic tool that we utilized to make decisions at the charge-nurse level, where our most effective staffing interventions could be made to affect the changes we were seeking.

Instead of one person spending 95% of their reps in your room, now there are three people who spend 30 percent of their reps in a room, maintaining proficiency because of their continued frequent touch points. Sure, there were surgeon complaints, but guess what else the tool did? It was a ready-made report to show surgeons where their team was allocated. Most of the time they actually agreed wholeheartedly with the assignments our leaders where making.

Total success

We believe this tool, which has been replicated in more than one facility, is an example of intelligence that could take us to the next level of variability reduction and a more perfect system to support human success. With human factors being so enmeshed in preventing RSIs and URSIs, is it possible to ever get to zero incidents?

My humble answer is this: As soon as we have artificial intelligence (AI) and robots monitoring, managing, and designing our systems, we can improve drastically. Humans can operate at a pretty high level. But AI and robotics can help perfect our human responses. OSM